265. Endocrine emergencies Flashcards
What are the signs of DKA?
Gradual drowsiness, vomiting and dehydration
Ketotic breath, abdo pain, kussmaul breathing
What is meant by kussmaul breathing
deep laboured gasping breathing seen in DKA
What triggers a DKA?
Infection MI Pancreatitis (however serum amylase may be coincidentally raised) Chemo Antipsychotics Insulin non compliance
What three criteria are required to diagnose DKA?
Acidaemia (venous blood pH<7.3 or HCO3 <15mmol/L)
Hyperglycaemia (glucose>11 or known DM)
Ketonaemia (>3.ommol/L) or significant ketonuria (>2+)
When should you consider transfer of the patient to HDU/ITU?
Blood ketones>6 Bicarb<5 pH<7 K<3.5 GCS<12 sats<92 BP<90 systolic Pulse outwith normal parameters (60-100)
Discuss the fluid requirements in an individual with DKA?
Typical fluid deficit is around 1L/10kg
0.9 % saline is the fluid of choice
So for 70Kg male:
1L in 1 hour (unless BP<90 systolic)
1L in 2 hours (x2)
1L in 4 hours (x2)
1L in 8 hours
bicarbonate may increase risk of cerebral oedema and is not used
Discuss the need for potassium replacement in those with a DKA?
Depending on U&E’s add potassium to every bag after 1st bag:
K >5.5- Nil
K-3.5-5.5- 40mmol
K <3.5- get HDU involvement
What is the treatment plan for DKA?
ABC and 2 large bore cannula
Fluid resus if required, if not start first bag over 1h
VBG,pH, bicarb, bedside lab glucose and ketones, bloods, check every 2 hours at least
Insulin- add 50 units per bag, continues patients normal insulin regime,
Check cap blood glucose and ketones hourly
Monitor urine output
When glucose <14mmol start 10% with insulin to avoid hypo
What can be said when looking for infection in DKA?
High WCC may be seen without infection
Have low suspicion, do MSSU, blood cultures and CXR
How may a DKA reoccur quickly after treatment?
Blood glucose may resolve before ketones do
Premature insulin discontinuation may lead to DKA
Avoid by keeping glucose and insulin infusion until ketones <0.5
What are the signs of a hypo?
Rapid onset, odd behaviour
Sweating, pulse, seizures
Once a hypo has been confirmed how is it managed?
Give 15-20g of a quick acting carbohydrate snack (e.g O.J.) (repeat up to 3 times every 15 mins)
If unconscious start glucose infusion or give glucagon
Once blood glucose above 4 give toast
What is hyperglycaemic hypersosmlar state, how is it treated?
Type 2 DM, dehydration and glucose >30
Give LMWH to all that can take it
Rehydrate slowly with 0.9% saline. Replace potassium when urine comes
What drug should be stopped in diabetics with a lactic acidosis
Metformin
What is myxoedema coma?
The ultimate hypothyroid state before death
What are the signs and symptoms of myxoedema coma?
Looks hypothyroid, often >65
hypothermia, low glucose, bradycardia
coma, seizures
goitre, cyanosis, low BP, HF
What is the treatment of myxoedema coma?
ICU
Bloods for T3, T4, TSH, FBC, U&E’s, ABG
Give T3 slowly
Give hydrocortisone if pituitary hypothyroidism is suspected
What are the complications seen in myxoedema coma?
Hypoglyceamia, pancreatitis, arrythmias
What is a hyperthryoid storm?
Severe hyperthyroidsim increased temp, agitatioon, confusion,coma
Who tends to get a hyperthyroid storm?
Recent thyroid surgery or radioiodine
Infection, MI, trauma
What are the goals of treatment in a hyperthyroid crisis?
Counteract peripheral affects of thyroid hormones
Inhibit thyroid hormone synthesis
Treat systemic complications
What is the management plan for a thyrotoxic storm?
IV access, fluids if dehydrated, NG if Vom
Take bloods for T3, T4, TSH, cultures
sedate if necessary, give propanalol to reduce heart rate/digoxin
Antithyroid drugs (carbimazole)
Hydrocortisone to prevent peripheral conversion
What are the causes of an Addisonian crisis?
Infection, trauma, surgery, missed medication
How does an Addisonian crisis present?
Shock (increased HR, vasconstriction, postural hypotension)
hypoglycaemia
How do you manage an addisonian crisis?
Bloods for cortisol AND Acth
Hydrocortisone
IV fluid bolus
Change to oral steroids after 72 hours
Hypopituitary coma should be suspected when a patient presents with hypothermia, refratory hypotension and septic signs
How is it treated?
Dont wait for lab results
Hydrocortisone
Liothyroxine (T3)
Patients with phaeochromocytma may present with hypertensive crisis. How is this treated?
Short acting alpha blocker
Long acting alpha blocker, when BP stable
B blocker to control any tachycardia/arrythmias
